Pupillary Block Glaucoma Research Articles

Lentes fácicas de câmara anterior

The phakic intraocular lenses (pIOLs) are a good option for the correction of high refractive errors. According to their anatomical position there are two types of pIOLs: anterior or posterior chamber. The anterior chamber pIOL may be iris-fixated or angle-supported. The iris-fixated pIOLs are available not only for myopia correction, but also for hyperopia and astigmatism. During the last decades many modifications on the pIOLs designs were proposed in order to reduce late complications, such as progressive endothelial cell loss. Acute endothelial cell trauma related to the surgical procedure may be minimized with proper intraoperative care. Advances in the preoperative screening methods have improved the safety of the procedure. Estimation of the pIOL power is based on the van der Heijde calculations and is dependent on the anterior chamber depth, the spherical equivalent and the mean keratometric values. Long-term results show the efficacy, predictability and safety of the procedure. According to the type of the pIOL, complications other than endothelial cell loss include iritis, pigment dispersion, iris atrophy, pupil ovalization, pIOL rotation, decentration or dislocation, intraocular pressure elevation and pupillary block glaucoma. Foldable models actually available show promising results with lower complication rate.

Mid-long term follow-up results in correction of extreme myopia by posterior chamber phakic intraocular lens

To evaluate the mid-long term stability and safety of posterior chamber phakic intraocular lens (ICL) implantation for the correction of extreme myopia. This retrospective study included 993 eyes of 498 patients received ICL implantation from June 1996 to December 2008. Multivariate analysis and variance analysis were used to evaluate the stability of the results and to identify risk factors of the complications. Successful implantation was achieved in all patients. Spherical equivalent (SE) was (16.23 ± 4.12, mean ± SD) D before the operation and (-0.92 ± 1.22) D at the last examination. Intraocular pressure was (13.58 ± 2.93) mm Hg (1 mm Hg = 0.133 kPa) preoperatively which was (13.90 ± 3.01) mm Hg at the last examination. There was no statistical significance in follow-up (t = 0.44 ∼ 1.30, P > 0.05). Endothelial cell density was (2858.21 ± 395.13)/mm(2) before the operation and (2567.19 ± 423.45)/mm(2) at last examination. Pupillary block glaucoma occurred in 2 eyes (0.2%) at two hours and 1 eye (0.1%) at one month after the operation. Three eyes developed anterior cataracts between 6 months to 1 year after ICL implantation and another 2 eyes subcapsular opacification at semi-peripheral regions occurred 4 years after the operation, and was not related with age, SE and vaults (F = 2.42, 1.98, 0.81, P > 0.05). Macular puckers were found in 5 eyes (0.5%) 1 year postoperatively, including 2 eyes developed choroidal neovascularization and received PDT, best corrected visual acuity lost more than 2 lines. Retinal detachment occurred in 2 eyes at 1.5 years after the operation. Acute iritis happened in 1 eye (0.1%) and chronic iritis in 1 eye (0.1%) which combined with slight pupil distortion and elevation of intraocular pressure. Iris stroma atrophy and pupil distortion were found in 2 eyes (0.2%). Correction of high myopia by ICL implantation is a safe procedure and the results are stable.

Fibrin membrane pupillary-block glaucoma after uneventful cataract surgery treated with intracameral tissue plasminogen activator: a case report

BackgroundFibrin pupillary-block glaucoma is a rare complication after cataract surgery. The treatment for this condition is still controversial, since Nd:YAG laser fibrin membranotomy tends to reocclude and laser peripheral iridotomy entails the risk of damaging the corneal endothelium in the presence of corneal edema associated with elevated intraocular pressure.Case presentationA 62-year-old man with diabetes mellitus developed acute elevation of intraocular pressure with a shallow anterior chamber five days after uneventful cataract surgery. Initially, slit lamp examination provided only limited information due to severe corneal edema. After resolution of corneal edema with systemic glaucoma therapy, a complete fibrin membrane was observed across the pupil by slit lamp examination. Anterior segment optic coherence tomography clearly revealed a thin fibrin membrane covering the entire pupillary space, a shallow anterior chamber, and a deep posterior chamber. The intraocular lens was not observed by anterior segment optic coherence tomography. In contrast, ultrasound biomicroscopy, which has superior penetration depth, was able to visualize the intraocular lens deep in the posterior chamber. Injection of tissue plasminogen activator into the anterior chamber resulted in complete fibrinolysis and released the pupillary block.ConclusionThis case suggests that ocular anterior segment imaging modalities, especially ultrasound biomicroscopy, serve as powerful diagnostic tools to identify mechanisms of acute angle closure glaucoma, which is often accompanied by poor intraocular visibility. This is the first reported case of fibrin pupillary-block glaucoma after cataract surgery successfully treated with intracameral tissue plasminogen activator.

Scheimpflug Imaging in Unilateral Acute Pupillary Block Glaucoma in a Weill-Marchesani Syndrome in an Adult Female

ABSTRACT We report an interesting case of Weill-Marchesani syndrome presenting as unilateral acute pupillary block glaucoma after dislocation of crystalline lens into anterior chamber in a middleaged woman. Scheimpflug imaging demonstrated accurately the dimensions of spherophakic crystalline lens and its corneal lenticular touch. Glaucoma resolved completely after lensectomy and anterior vitrectomy and she achieved best corrected visual acuity of 20/30. How to cite this article Chaudhary M, Ram J, Gupta N, Verma N. Scheimpflug Imaging in Unilateral Acute Pupillary Block Glaucoma in a Weill-Marchesani Syndrome in an Adult Female. J Postgrad Med Edu Res 2012;46(3):152-154.

Pupillary block glaucoma secondary to vitreous prolapse after Nd:YAG capsulotomy

The problems caused by posterior capsular opacification can be remedied effectively with neodymium‐doped yttrium aluminium garnet(Nd:YAG) capsulotomy by creating an opening in the posterior lens ca...

Corneal chromoblastomycosis caused by Cladophialophora carrionii after cataract surgery

We describe a case of corneal chromoblastomycosis with Cladophialophora carrionii in a 69-year-old woman 4 weeks after clear corneal cataract surgery. The patient presented with right eye pain and decreased visual acuity of 20/100. Examination showed a deep posterior stromal keratitis accompanied by a dense fibrinous anterior chamber reaction. An aqueous tap was performed, and the patient was treated with topical, systemic, and intracameral antifungal and antibiotic agents. The infection was resistant to medical therapy and the course further complicated by secondary pupillary block glaucoma. After 10 days, a therapeutic penetrating keratoplasty was performed. The patient remained asymptomatic 20 months after the initial presentation, with corrected distance visual acuity restored to 20/40. To our knowledge, is the first reported case of corneal chromoblastomycosis with C carrionii. Early surgical treatment may be necessary to eradicate Cladophialophora species.

Ultrasound biomicroscopy in pupillary block glaucoma secondary to ophthalmic viscosurgical device remnants in the posterior chamber after anterior chamber phakic intraocular lens implantation

A 25-year-old woman developed pupillary block glaucoma in the right eye after implantation of an angle-supported phakic intraocular lens despite a preexisting moderate-sized iridectomy. Ultrasound biomicroscopy (UBM) showed ophthalmic viscosurgical device retention in the posterior chamber and a full-thickness, patent-appearing iridectomy at 12 o'clock. The intraocular pressure gradually decreased to normal after a neodymium:YAG laser iridotomy was performed midperipherally at 9 o'clock. To our knowledge, this is the first report of UBM findings of this complication.

Comparison of clear lens extraction and collamer lens implantation in high myopia

To compare the outcomes of clear lens extraction and collamer lens implantation in high myopia. Myopic patients younger than 40 years old with more than 12 diopters of myopia or who were not fit for laser-assisted in situ keratomileusis were included. Group 1 comprised patients undergoing clear lens extraction and Group 2 patients received the Visian implantable collamer lens. Outcome and complications were evaluated. Postoperative best corrected visual acuity was -0.61 +/- 0.18 in Group 1 and 0.79 +/- 0.16 in Group 2. In Group 1, 71.4% achieved a postoperative uncorrected visual acuity better than the preoperative best corrected visual acuity, while only 51.8% patients achieved this in Group 2. Intraocular pressure decreased by 12.55% in Group 1, and increased by 15.11% in Group 2. Corneal endothelial cell density decreased by 4.47% in Group 1 and decreased by 5.67% in Group 2. Posterior capsule opacification occurred in Group 1. In Group 2, lens opacification occurred in 11.11%, significant pigment dispersion in 3.7%, and pupillary block glaucoma in 3.7%. Clear lens extraction presents less of a financial load up front, and less likelihood of the need for a secondary intervention in the future. Clear lens extraction is a more viable solution in developing countries with limited financial resources.

Effect of incision width on graft survival and endothelial cell loss after Descemet stripping automated endothelial keratoplasty.

To assess the effect of incision width (5.0 and 3.2 mm) on graft survival and endothelial cell loss 6 months and 1 year after Descemet stripping automated endothelial keratoplasty (DSAEK). One hundred sixty-seven subjects with endothelial decompensation from a moderate-risk condition (principally Fuchs dystrophy or pseudophakic corneal edema) underwent DSAEK by 2 experienced surgeons. The donor was folded over and inserted with single-point fixation forceps. This retrospective analysis assessed graft survival, complications, and endothelial cell loss, which was calculated from baseline donor and 6-month and 1-year postoperative central endothelial images evaluated by an independent specular microscopy reading center. No primary graft failures occurred in either group. One-year graft survival rates were comparable (98% vs 97%) in the 5.0- and 3.2-mm groups, respectively (P = 1.0). Complications included graft dislocation, graft rejection episodes, and elevated intraocular pressure and occurred at similar rates in both groups (P > or = 0.28). Pupillary block glaucoma did not occur in either group. Mean baseline donor endothelial cell density did not differ: 2782 cells per square millimeter in the 5.0-mm (n = 64) and 2784 cells per square millimeter in the 3.2-mm (n = 103) groups. Percent endothelial cell loss was 27% +/- 20% (n = 55) versus 40% +/- 22% (n = 71; 6 months) and 31% +/- 19% (n = 45) versus 44% +/- 22% (n = 62; 12 months) in the 5.0- and 3.2-mm incision groups, respectively (both P < 0.001). One year after DSAEK, overall graft success was comparable for the 2 groups; however, the 5.0-mm incision width resulted in substantially lower endothelial cell loss at 6 and 12 months.

Descemet Stripping Automated Endothelial Keratoplasty in the Phakic Eye

To evaluate the visual acuity, graft clarity, refractive outcome, and crystalline lens clarity in phakic patients undergoing Descemet stripping automated endothelial keratoplasty (DSAEK). Six eyes of 4 consecutive patients with clear crystalline lenses and corneal edema because of either Fuchs dystrophy (4 eyes) or amantadine-induced corneal endothelial toxicity (2 eyes) were included in this study. All patients underwent simple DSAEK using a 4.2-mm temporal clear corneal incision. The 8.5-mm donor lenticule was folded and inserted into the anterior chamber using an Utrata forceps. A 10-minute air bubble tamponade was used. Best-corrected spectacle visual acuity, refractive error, graft status, and crystalline lens clarity were measured at a minimum of 6 months postoperatively. All grafts for Fuchs dystrophy remained clear, whereas 2 grafts failed because of continued amantadine corneal toxicity. Excluding the failed grafts, the average preoperative best-corrected spectacle visual acuity was 20/47 compared with 20/28 postoperatively (P = 0.0024). There were no intraoperative complications, and no eyes developed pupillary block glaucoma or cataracts during an average follow-up interval of 9.1 months (6-14 months). DSAEK may be safely performed in the phakic eye.

God made capsulorrhexis

As early as 1764, Morgagni, the famous anatomist wrote in his book “The seats and causes of disease” about hypermature cataracts in the elderly [1]. This is a type of hypermature cataract which is still known by his name-the Morgagnian cataract. A morgagnian cataract is a hypermature cataract in which total liquefaction of the cortex allows nucleus to sink inferiorly [2]. Spontaneous anterior capsular opening in form of capsulorrhexis is an extremely rare presentation in morgagnian cataract and in it, pupillary block glaucoma usually occurs due to intumescence of lens [3]. We report an extremely rare case of spontaneous anterior capsular opening (God made capsulorrhexis) in morgagnian cataract resulting in expulsion of morgagnian nucleus which was caught and suspended at the pupil causing pupillary block glaucoma.

Pupillary Block Glaucoma After Pars Plana Vitrectomy with Air-Fluid Exchange in Pseudophakic Air-Filled Eye.

Pupillary block is seen after pars plana vitrectomy (PPV) with gas or silicone oil endotamponade in aphakic eyes. A case of a pseudophakic patient with pupillary block glaucoma related to the migration of air into the anterior chamber was reported. A 76-year-old woman underwent combined PPV with air endotamponade and uncomplicated cataract extraction for epiretinal membrane and cataract. On postoperative day 1, she had an 80% air fill of the anterior chamber. She returned 6 days later with pupillary block glaucoma. She was managed with a surgical peripheral iridectomy, posterior synechiolysis, and evacuation of the air from the anterior chamber. The risk of pseudophakic pupillary block glaucoma after PPV with air tamponade may be increased with inflammation due to combined PPV and cataract extraction, zonular weakness, and efflux of air from the vitreous cavity into the anterior chamber. Early detection and treatment is recommended to avoid permanent sequelae.

Pupillary Block Glaucoma After Implantation of Iris-Fixated Phakic Intraocular Lens.

To report a case of pupillary block glaucoma after implantation of iris-fixated phakic intraocular lens (IF pIOL). A 43-year-old man was referred for pupillary block one day after implantation of IF pIOL. Slit-lamp examination revealed extremely shallow anterior chamber, closure of peripheral laser iridotomy and contact of iris on the peripheral of the optics of IF pIOL. The intraocular pressure (IOP) was 62 mm Hg. The iris moved forward in contact with the IF pIOL and the lens remained in the physiologic position, which made the distance between the lens and the iris wide. He underwent an uneventful peripheral surgical iridectomy and the IOP decreased to 6 mm Hg. Acute pupillary block glaucoma can occur after IF pIOL implantation due to the occlusion of aqueous flow between the IF pIOL and the iris if the peripheral iridotomy closes.

Pupillary Block Glaucoma Secondary to Phacodonesis in Pseudoexfoliation.

The authors present a clinical case of unilateral narrow angle glaucoma in the setting of pseudoexofoliation (PXF) and review the relevant literature and treatment of pseudoexfoliaton-related angle closure. They describe a case of pupillary block with secondary angle closure resulting from anterior subluxation of the lens arising secondary to zonular weakness related to PXF. This mechanism is demonstrated with slit lamp exam and anterior segment ultrasound biomicroscopy (UBM). This case helps to document and better characterize the occurrence of narrow angles and angle closure glaucoma arising in PXF, an entity that is not well documented in the literature. The case also illustrates the need for periodic gonioscopy and examination of anterior chamber depth to evaluate for prophylactic peripheral laser iridotomy to prevent angle closure glaucoma in patients with PXF.

Descemetʼs stripping with automated endothelial keratoplasty and glaucoma

Descemet's stripping with automated endothelial keratoplasty (DSAEK) has recently become the preferred surgical procedure replacing penetrating keratoplasty (PKP) for corneal endothelial disorders. However, DSAEK may also be associated with postprocedure intraocular pressure elevation and secondary glaucoma, and presents unique surgical challenges in patients with preexisting glaucoma surgeries. The relatively high rate of glaucoma induction or worsening after PKP has significant implications leading to corneal graft failure and irreversible vision loss from glaucomatous optic neuropathy. In contrast, DSAEK, in addition to providing excellent visual outcomes with faster recovery, may provide advantages over PKP with lower risk of serious, vision-threatening glaucoma-related complications. Pupillary block glaucoma, steroid-induced intraocular pressure elevation, and less commonly peripheral anterior synechiae development have been reported after DSAEK. In patients with preexisting glaucoma surgical procedures (trabeculectomy or tube shunts), special attention to techniques (which continue to evolve) are required to perform DSAEK safely and effectively. As DSAEK continues to gain popularity and advance with more studies performed, our understanding of DSAEK-associated intraocular pressure elevation and secondary glaucoma-related complications will become more complete. Current limited data suggest that DSAEK may be a suitable surgical alternative to PKP in patients with corneal endothelial disease and coexistent glaucoma with or without prior glaucoma procedures with faster recovery and good visual outcomes.

Phakic Intraocular Lenses

The use of phakic intraocular lenses (PIOLs) is a small but emerging area in refractive surgery. For patients with high myopia and inadequate vision with glasses or intolerance to contact lenses, options are limited. Corneal refractive surgery such as LASIK can safely and reliably correct myopia up to approximately – 12 diopters, but at higher diopters it achieves less satisfactory results along with increased risks of corneal ectasia. In addition, intraocular lens (IOL) implantation with lensectomy yields loss of accommodation, along with increased risks of retinal detachment in high myopes. The advent of PIOLs offers the possibility of refractive correction without the loss of accommodation. However, their insertion is not without challenges. The incisional surgery required for implantation can lead to complications that include endophthalmitis, induced astigmatism, damage to the corneal endothelium, iris ovalization secondary to ischemia or entrapment, chronic uveitis, pupillary block glaucoma, pigment dispersion syndrome, and cataracts. Other considerations are the special techniques required for lens calculation and surgical lens implantation, usually preceded by peripheral laser iridotomy. Furthermore, because this is still an emerging area of refractive surgery, long-term outcomes are unknown and data are limited. This article aims to review the most recent reports on the 3 types of phakic intraocular lenses: angle-supported PIOLs, iris-supported PIOLs, and posterior chamber PIOLs.

Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK) Using Corneal Donor Tissue Not Acceptable for Use in Penetrating Keratoplasty as a Result of Anterior Stromal Scars, Pterygia, and Previous Corneal Refractive Surgical Procedures

The purpose of this study was to evaluate outcomes of Descemet's stripping automated endothelial keratoplasty (DSAEK) using anterior stromal flawed (ASF) donor corneas that were unsuitable for use in full-thickness penetrating keratoplasty as a result of stromal scars, pterygia, or previous corneal refractive surgery and to compare results with DSAEK using standard tissue. We conducted a review of our initial 42 (19 with 6-month follow up) consecutive DSAEK surgeries using ASF tissue compared with 357 (199 with 6-month follow up) time-matched controls using standard tissue. Intraoperative and perioperative complications, including dislocations and primary graft failures, were compared. Six-month best spectacle-corrected vision, incidence of rejection episodes, postoperative refractive astigmatism, keratometric values, pre- and postoperative topography-derived surface asymmetry index, and surface regularity index were compared. One surgeon-cut ASF tissue was perforated before surgery and was discarded. No surgeon-cut standard tissue was perforated. No intraoperative complications and no episodes of primary graft failure or pupillary block glaucoma occurred in either group. One (2.4%) postoperative graft dislocation and one (5.2%) graft rejection episode occurred in the study group. There were 10 (2.8%) dislocations and 8 (2.2%) graft rejection in the controls. A statistically similar significant improvement in best spectacle-corrected vision occurred in both groups. Corneal topography, pachymetry, and manifest astigmatism were not significantly different between groups. Postoperative results of DSAEK using donor tissue excluded from use in penetrating keratoplasty as a result of stromal flaws are equivalent to results using standard donor tissue. Central corneal thickness measurements should be performed before cutting to avoid tissue perforation. The use of ASF tissue for DSAEK will expand the cornea donor pool.

The Enigma of Galileo's Eyesight: Some Novel Observations on Galileo Galilei's Vision and His Progression to Blindness

Galileo Galilei became blind. Before this happened he revealed that his left eye had always had less than perfect vision. A study of his written works, his handwriting, and the originals of the portraits undertaken during his lifetime indicate that this probably was the case. These portraits suggest that his left eye tended to lose fixation and that, at the age of 60, he suffered from a mucocoele of the right frontal sinus; but these conditions would not have caused blindness. Considering the systemic diseases from which he suffered over his lifetime, he could possibly have had a long standing uveitis with secondary pupillary block glaucoma, common in those with the group of conditions classified as sero-negative arthropathies. Posterior scleritis with secondary glaucoma is less likely. If either of these were the cause, then the disease was probably triggered by a well-documented, severe acute illness as a young adult, the inflammation being localized to the eye as a result of severe recurrent conjunctival infections in his youth. The intermittent nature of the visual loss, the normal appearance of the cornea and pupils in his portraits, the absence of any evidence of inflammatory joint disease, the presence of halos, and the severe nature of the pain—combined with the high level of visual acuity in between attacks and its persistence until the last few weeks of vision means that angle-closure glaucoma must also be considered. These suggestions might be confirmed or refuted by studying his remains. Application has been made for this to be done.

Anterior segment imaging in the management of postoperative fibrin pupillary–block glaucoma

Postoperative fibrin pupillary-block glaucoma, an uncommon complication of intraocular surgery, develops when an inflammatory fibrin membrane occludes the pupil, resulting in peripheral angle closure. We present a series of 4 patients with this condition and describe the role of anterior segment optical coherence tomography and ultrasound biomicroscopy in distinguishing fibrin pupillary-block glaucoma from other forms of postoperative acute glaucoma. Specific to this condition is the presence of a fibrin membrane across the pupil and accumulation of aqueous in the posterior chamber, as would be expected in pupil block, but with a clear separation between the intraocular lens and the iris. The possible risk factors are discussed and various treatment modalities reviewed.

Pupillary block glaucoma in phakic eyes using 5000 centistoke silicone oil.

To describe pupillary block glaucoma in phakic patients undergoing vitrectomy and 5000 centistoke silicone oil injection. Observational case reports. Vitrectomy and higher-viscosity silicone oil injection was performed in two phakic patients with proliferative diabetic retinopathy. Both patients developed a pupillary block in the early postoperative period (1 week and 1 month after surgery). Unnoticed zonulysis during surgery, thought to be the main contributory cause, allowed access of the silicone oil between the iris and the lens. Although higher-viscosity silicone oil was used in both cases, an acute glaucoma developed. An inferior iridotomy was performed, resulting in a temporary resolution of the pupillary block. Vitreoretinal surgeons should be aware of silicone-induced pupillary block glaucoma in phakic eyes, even when higher-viscosity silicone oils are used.